Nokea
A patient at 36 weeks gestation is undergoing a nonstress test (NST). The nurse observes the fetal heart rate baseline at 135 bpm and four nonepisodic patterns of the fetal heart rate reaching 160 bpm for 20-25 seconds each. How will the nurse record these findings?
- A. NST positive, nonreassuring
- B. NST negative, reassuring
- C. NST reactive, reassuring
- D. NST nonreactive, nonreassuring
Correct Answer: C
Rationale: An NST is reactive and reassuring when two or more accelerations occur within 20 minutes, indicating fetal well-being.
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A pregnant patient at 24 weeks gestation reports feeling fatigued and lightheaded. What is the nurse's first priority action?
- A. Encourage the patient to rest and drink fluids.
- B. Monitor the patient's blood pressure and assess for signs of anemia.
- C. Administer iron supplements to alleviate fatigue.
- D. Instruct the patient to avoid any physical activity until symptoms subside.
Correct Answer: B
Rationale: The correct answer is B. Monitoring the patient's blood pressure and assessing for signs of anemia is the first priority because fatigue and lightheadedness in pregnancy can be symptoms of anemia or other serious conditions. Anemia can lead to complications for both the mother and the baby. Encouraging rest and fluids (choice A) is important but should come after ruling out any potential serious conditions. Administering iron supplements (choice C) without proper assessment can be harmful if anemia is not the cause. Instructing the patient to avoid physical activity (choice D) without proper evaluation can delay necessary interventions.
A client enters the prenatal clinic. She states that she missed her period yesterday and used a home pregnancy test this morning. She states that the results were negative, but 'I still think I am pregnant.' Which of the following statements would be appropriate for the nurse to make at this time?
- A. Your period is probably just irregular.
- B. We could do a blood test to check.
- C. Home pregnancy test results are very accurate.
- D. My recommendation would be to repeat the test in one week.
Correct Answer: B
Rationale: A blood test is more accurate than a home pregnancy test, especially early in pregnancy. Repeating the test in a week is also an option, but a blood test provides more immediate and reliable results.
How often should the nurse assess the blood pressure, pulse, and respirations of the birthing person during the first hour of the fourth stage of labor?
- A. every 15 minutes
- B. every 30 minutes
- C. not until after the first hour
- D. once, then hourly
Correct Answer: A
Rationale: The correct answer is A: every 15 minutes. During the first hour of the fourth stage of labor, immediate postpartum assessment is crucial to monitor for any signs of complications such as hemorrhage or shock. Assessing vital signs every 15 minutes allows for early detection of any abnormalities and prompt intervention. This frequency ensures close monitoring of the birthing person's condition and helps in early identification of any potential issues. Choices B, C, and D are incorrect because less frequent assessments may delay the identification of complications, potentially leading to serious consequences. Option C, in particular, is dangerous as it suggests delaying assessments when immediate postpartum monitoring is essential.
Organize the developmental stages in the correct order. Put a comma and space between each answer choice (a, b, c, d, etc.)
- A. Zygote
- B. Morula
- C. Blastocyst
- D. Embryo
Correct Answer: B
Rationale: Fetal development progresses through several stages: zygote, morula, blastocyst, embryo, and fetus. Each stage represents a critical phase in the formation and growth of the embryo.
The nurse is caring for a pregnant patient who is at 30 weeks gestation and has been diagnosed with gestational diabetes. Which of the following is the most important aspect of the patient's care plan?
- A. Maintaining a healthy weight gain during pregnancy.
- B. Monitoring blood glucose levels and maintaining a balanced diet.
- C. Increasing fluid intake to reduce the risk of dehydration.
- D. Administering insulin to control blood sugar levels.
Correct Answer: B
Rationale: The correct answer is B: Monitoring blood glucose levels and maintaining a balanced diet. This is the most important aspect of care for a pregnant patient with gestational diabetes because it helps control blood sugar levels, reducing the risk of complications for both the mother and the baby. Monitoring blood glucose levels ensures that the patient's blood sugar remains within the target range, while maintaining a balanced diet helps provide essential nutrients without causing spikes in blood sugar levels.
A: Maintaining a healthy weight gain during pregnancy is important but not as crucial as monitoring blood glucose levels for a patient with gestational diabetes.
C: Increasing fluid intake is important for overall health during pregnancy, but it is not the most critical aspect of care for a patient with gestational diabetes.
D: Administering insulin may be necessary in some cases, but it is not the most important aspect of care compared to monitoring blood glucose levels and maintaining a balanced diet.